Aaron Glickman

Lack of transportation has been an enduring barrier to care, especially for low-income and rural patients. Many of these patients are covered by Medicaid, which, since 1966, has provided non-emergency transportation (NEMT) to medical appointments for free or at a heavily subsidized rate. Although NEMT is built into the foundation of Medicaid, some state governments are seeking leeway to drop that benefit. The movement stems from persistent budget constraints and a view that NEMT is ineffective.

Novel gene and cell therapies hold out the promise of a cure for previously incurable conditions, often at eye-popping prices. Last month, more than 75 health policy and biomedical researchers, federal and state regulators, and clinicians convened at the Cost of a Cure Conference at the University of Pennsylvania to discuss key political, economic, and clinical challenges to the future of gene and cell therapies.

A review of the evidence shows that bundled payments for surgical procedures can generate savings without adversely affecting patient outcomes. Less is known about the effect of bundled payments for chronic medical conditions, but early evidence suggests that cost and quality improvements may be small or non-existent. There is little evidence that bundles reduce access and equity, but continued monitoring is required.

Biomedical advances in genomics and oncology, combined with rising costs for targeted cancer therapies, challenge the way we currently deliver and pay for cancer care. To foster the economic sustainability of targeted therapies, the University of Pennsylvania convened the Gant Family Precision Cancer Medicine Consortium, a multidisciplinary work group of experts from health care economics, policy, law, regulation, biomedical research, patient advocacy, and the pharmaceutical and insurance industry.

In a recent Scattergood Foundation report, LDI Senior Fellow Dominic Sisti and I tackle the curious case of the “institutions for mental diseases” (IMD) exclusion in Medicaid. For non-elderly adults, the national IMD exclusion prevents Medicaid from paying for inpatient care in institutions with more than 16 beds that primarily provide care for persons with “mental diseases” other than dementia or intellectual disabilities.

Engaging patients, families, and independent experts in policymaking is a laudable goal, but the process of doing so isn’t necessarily straightforward. If efforts to introduce patient and public perspectives also introduce bias, they may do more harm than good. A recent study raises concerns about bias in public engagement, finding that public engagement efforts by the Food and Drug Administration (FDA) may attract speakers with significant conflicts of interest (COI), which are frequently undisclosed.

Practice transformation and payment reform are defining features of contemporary health policy debates. The story goes like this: new provider organizations, such as Accountable Care Organizations (ACOs) are transforming care delivery from fragmented and volume driven to integrated and optimized for quality; meanwhile, innovative payment models, such as bundled payments and risk-based contracting, herald a national transition from fee-for-service (FFS) to value-based payments.

Discussions of drug pricing often link high prices with the need to promote innovation in the pharmaceutical industry. New technology can drive improved health outcomes, social welfare, and economic growth, but assigning value to specific innovations is technically difficult.

Affordability may be the most ubiquitous buzzword in health reform. In repeated surveys, Americans cite the affordability of health care as their top financial concern. Despite their handwringing, politicians often avoid defining what constitutes “affordable” health care, and both non-experts and seasoned policymakers seem to lack robust measures of affordability. How can the most important crisis in health care lack reliable metrics?

“Value” is more than a buzzword. In response to rising costs, payers, physicians, and patients have turned to value assessment frameworks to inform treatment plans and design sustainable budgets. However, the usefulness and potential of these tools remain murky. LDI’s 50th anniversary symposium convened a panel to elucidate key questions for the future of value frameworks—what does value mean to different stakeholders in the health care system? How should payers, doctors, and patients appraise the value of the care they receive?